E&M with 69210 and E&M with 17110

[Jlm1611]

I am a new coder. My doc keeps coding the encounter sheets charging high level visit code with 69210 for cerumen impaction. It is making me crazy!
This is how the visit reads and I'm not short cutting it, the actual documentation is this short:
Patient came in for ear wax removal. Ears were irrigated unclear clear. Post exam looked fine.

That's it! She checks the boxes 99309 (we are considered a skilled nursing facility) and checks 69210 for the cerumen removal.

Then same thing when a patient comes into clinic to have wart removal from the hands

Patient came in for wart removal. Cryotherapy applied to two warts on thumb. Retreat as needed.
She checks 99309 and box 17110.

Don't I just code 69210 for the first and 17110 for the second with NO E&M code?

She does the same thing others as well.......... EKG for baseline before starting a med she will code the EKG and a high level visit when there is no documentation that she even saw the patient for any "problem"

I really need some guidance here please before I speak to the medical director about her coding..
Thanks!

 

[Alicia Scott]

This must have been a problem for a while. Encounter forms are the bane of most coders. Trouble is the physician has not been properly educated on the codes or guidelines. Going to the director is a good thing if that is your chain of command.

 

[Jlm1611]

I did but I don't know for sure how to code them! I told the director, I'm told to do the best I can. Ok, so do I just code 69210 for the cerumen removal since there was no visit? Also the same for the wart cryotherapy. There was no exam just cryo done.

 

[Alicia Scott]

Well you do need to use an E/M code because the physician did evaluate and manage the encounter. However you can only code what is documented. It will be pretty low if there is only a sentence documentation.

 

[Jlm1611]

That's confusing because someone else told me not to use an E&M code because the doc didn't do an exam, just cleaned the ears so the only charge is for the cleaning. If the patient had come in for ear pain and the doc examined the ears and found the wax and decided to clean the ears out, then I would code both an E/M code and the cleaning code.. so now I'm confused =\ I really need the answer to this tomorrow one way or the other. Can you explain your reasoning to code a low E/M code plus the cleaning code? Also the same with the wart cryo

 

[Alicia Scott]

Let me get Laureen in here. I don't want to tell you something wrong. CPT is her baby.

 

[Alicia Scott]

From an experienced coder:
My provider is excellent at documenting and I believe it is Federal law that residents be seen every 6o days. Oregon has additional requirements also.
Dr. John does type level of exam on each patient, even the one without complaints and documentation is "No changes at this time". He has documented the review of information from nurses, information from patients ect. It's very rare that a patient has "No complaints" but it does happen and since they are required to be seen, this usually is a brief 99307 visit. As for the first question, the 69210, removal impacted cerumen is used when the procedure is done with curettes, otoscope and forceps or suction. This procedure the provider in the question performed sounds like a basic ear lavage, that would be included in 99309. The second question pertaining to the cryotherapy and 2 wart removal does sound like only the procedure was performed. Sometime my provider with document in the previous visit, (example: two warts, removed at next visit) since Dr. Johns goes out every week, he most likely would do the wart removal, while seeing other scheduled patients, therefore it would be a procedure code of 17110.
This is how I would code the scenario - that was fun.
Sometimes doctors want to code for trimming of nails, again if the patient has a systemic condition, that could cause complications if an inexperience person trimmed their nails, it will be paid by medicare with HCPCS codes and ICD-9 showing systemic condition. Oregon Medicaid includes it in the E/M . It's important to what the insurance guidelines and query the physician. I would be telling the provider in the above scenario that she is over coding, show her information from the CMS and other coding websites.